Address / Phone Number
My declaration of entitlement and eligibility
(for public funding)
I understand that by enrolling with this practice I will be enrolled with the PHO -Primary Health Organisation (PHO Name). My name, address and other identification details will be included on both the practice and PHO enrolment registers.
I understand that if I visit another provider where I am not enrolled, I may be charged a higher fee.
I have been given information about the benefits and implications of enrolment with the PHO and their contact details.
I have read and I agree with the Health Information Privacy Statement in the accompanying PHO information booklet.
I agree to inform the practice of any change in my eligibility.